Disclosure Information. What You Need to Know: Changes in OB/GYN Coding. Invalid Codes. Revised Diagnosis Codes. New Diagnosis Codes

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1 Disclosure Information What You Need to Know: Changes in OB/GYN Coding Joan Slager, DNP, CNM, CPC, FACNM I have the following financial relationship to disclose: Speaker s Bureau: Warner-Chilcott and I will not discuss off label use and/or investigational use in my presentation. Revised Diagnosis Codes 669 Acute kidney failure during labor and delivery 670 Major puerperal infection Invalid Codes Feeding problems in the newborn NEW: New Diagnosis Codes Benign endometrial hyperplasia Endometrial intraepithelial neoplasia (EIN) New Diagnosis Codes Puerperal endometritis, unspecified as to episode of care or not applicable Puerperal endometritis, delivered with mention of pp complication Puerperal endometritis, pp condition or complication 1

2 New Diagnosis Codes Puerperal sepsis, unspecified as to episode of care or not applicable Puerperal sepsis, delivered with mention of pp condition Puerperal sepsis, postpartum condition or complication New Diagnosis Codes 670.3x Puerperal septic thrombophlebitis 670.8x Other major puerperal infection New V Codes V15.83 Personal history of underimmunization status V26.42 Encounter for fertility preservation counseling V26.82 Encounter for fertility preservation procedure V87.43 Personal history of estrogen therapy Modifiers 21 Prolonged Evaluation & Management services Deleted in 2009 Use prolonged services codes instead When visit is more than 30 minutes beyond what is allowed for an evaluation and management visit Modifiers 22 Increased procedural services Services take 25% more than usual Document time and reason Estimate dollar amount Modifiers 52 Decreased procedural services 53 Discontinued procedure 2

3 Annual Plus Pregnancy Annual Scheduled Pregnancy Diagnosed Bill preventive visit ( , ), V72.31 Also bill confirmation of pregnancy (99212), V72.42 Don t bill V22 Annual Plus Pregnancy Arrives for annual knowing she s pregnant Bill confirmation of pregnancy 99212, V72.42 Annual Plus Pregnancy Annual with complaints Bill Evaluation and Management Visit with symptom or complaint. Can also bill V72.42 link to pregnancy test Avoid V22 Preventive Medicine Periodic Preventive Medicine Comprehensive History Comprehensive Exam Counseling, anticipatory guidance, risk factor reduction Lab tests, diagnostic procedures Based on age New and Established patient codes Preventative Medicine with Problem Options Do annual exam and schedule a visit to address the problem Address the problem and reschedule the annual Do annual and address the problem 3

4 Problem visit with Annual Consider Are you a PCP? Do you need a referral? Public Relations Nature of the problem Well Woman Exam with Problem(s) Option 1 Address problem and reschedule Prev. Med. Visit. Bill an E&M code ( , ) Option 2 Bill Prev. Med. Visit and an E&M visit with a -25 modifier. Option 3 Bill the Preventative Medicine Visit with a -22 modifier. -25 Use when separate, identifiable, unrelated service is provided at the same visit. NOT ACCEPTABLE: Menopause, contraception, diet, exercise ACCEPTABLE: Chest pain, breast mass, pelvic pain, depression -25 Code for well woman exam Code with 25 modifier for separate problem Level of visit is based on history, exam, and MDM for the problem only. Sample 22 yo new patient presents for annual and to initiate contraception. Diagnosed vaginitis as well. Annual plus Procedure Annual exam done and cervical polyp noted and removed V

5 Preventive Services/Procedure New Pt Established Pt. V Local excision of lesion Mucous polyp of cervix Add 25 modifier to Prev. Med. Code Wet Smears Smear, primary source with interpretation If wet mount and KOH done report twice Whiff test is part of KOH test. Medicare Q0111 wet mount Q0112 KOH preparation Annual plus Counseling 35 year old G1 P1 established patient presents for annual and wishes to discuss infertility she has been trying to conceive for 1 year. Her first child is 2 ½. Annual done 15 minutes face to face additional time spent discussing fertility awareness, treatment options, workup. Office visit without exam To Bill for Counseling: If a diagnosis code E&M code Based on time Record time spent face to face with patient. New or Established Patients Counseling: minutes minutes minutes minutes minutes minutes minutes minutes minutes New Patients 5

6 Established Patients minutes minutes minutes minutes minutes Billing E/M Visits based on TIME More than 50% of face to face time with the patient is spent providing counseling or discussing treatment options Document Total time spent with patient: 30/40 for example The fact that >50% time spent counseling patient and/or family The content of the counseling or coordination of care Billing based on time? If NOT billing based on time DO NOT document the time spent with the patient. Maternity Care and Delivery Vaginal Delivery, Antepartum and Postpartum Care Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care. Transfer/Discontinued Care Late to care Miscarriage Transfers in or out of practice Antepartum Care Only Antepartum care only 4-6 visits AP care 7 or more visits <4 visits, bill each visit as an E/M code 6

7 Less than 4 visits Obstetrics Bill E&M codes for each visit Initial visit Revisit (for example) V23.7 Insufficient PNC (Reduced Services) One visit Vaginal delivery only including postpartum care Delivery Only vaginal delivery only delivery plus pp care Covers ONLY delivery Can bill admission The 3 day induction First hospital day Subsequent hospital days Billing Outside the Global Additional Antepartum Services Services to treat conditions unrelated to pregnancy Services to treat complications of pregnancy Transfer/Discontinued Care Ultrasound Procedures Global Periods Evaluation & Management Services that are performed during a global period may require a modifer 24 modifier Unrelated E&M service by the same physician during a post operative period. 7

8 Maternity Care and Delivery Antepartum Services Fetal non-stress test CST Radiology Codes BPP Limited Ultrasound (fetal heart beat, placental location, fetal position, and/or AFI) Non Stress Tests Use a fetal diagnosis If evaluating contractions part of global Must be read by billing provider Use Modifier -26 if only professional component done Interruption of Pregnancy/Stillbirth Any delivery after 20 weeks 0 days is reported using a delivery code When reporting a global delivery code (59400) it may be appropriate to add a modifier 52 (reduced services) if the number of prenatal visits is substantially less than 13. Episodic E&M Visit during Pregnancy Documentation must include history, physical and medical decision making specific to the problem. Choose appropriate E&M code ICD-9 code Pregnancy is coded as incidental Bill on day of service Ear Ache Headache URI Flu Conditions Unrelated to Pregnancy Are you a PCP? PCP-Primary Care Provider YES! Can treat (and bill) outside of pregnancy No Must obtain a referral Or refer to PCP 8

9 Episodic visits during pregnancy Document the problem as Incidental to the pregnancy (V22.2) Complicating the pregnancy (600 series) E/M Visits during pregnancy Related to pregnancy Bill at end of pregnancy if >13-15 visits The visits falling outside of the AP schedule are E/M visits. Monitoring High Risk Patients Monitoring for a problem that never materializes the additional visits are not reported separately bill global instead Complications of Pregnancy Preterm Labor Placenta Previa Gestational Diabetes Coding for Pregnancy Complications Pregnancy at risk due to history V code Elderly primigravida V23.81 Insufficient prenatal care V23.7 Pregnancy complicated by ICD-9 numeric code Anemia Breech presentation Risk Factors V23.0 Pregnancy with Hx of Infertility V23.4 Pregnancy with other poor obstetrical hx. (conditions ) V23.7 Insufficient Prenatal Care V23.83 Young Primigravida (<16) Pregnancy Complicated By Mild or unspecified pre-eclampsia Threatened premature labor Abnormal glucose tolerance Oligohydramnios 9

10 Preterm Labor 2/14/02 Initial Visit 12 weeks 3/14/02 OB revisit 16 weeks 4/11/02 OB revisit 20 weeks 5/9/02 OB revisit 24 weeks 5/15/02 prob visit PTL 25 weeks 5/22/02 OB revisit 26 weeks 5/29/02 OB revisit 27 weeks 6/4/02 OB visit 28 weeks 6/11/02 OB visit 29 weeks 6/13/02 OB visit 29 weeks Delivered 6/18/02 Preterm Labor 2/14/02 Initial Visit 12 weeks 3/14/02 OB revisit 16 weeks 4/11/02 OB revisit 20 weeks 5/9/02 OB revisit 24 weeks 5/15/02 prob visit PTL 25 weeks 5/22/02 OB revisit 26 weeks 5/29/02 OB revisit 27 weeks 6/4/02 OB visit 28 weeks 6/11/02 OB visit 29 weeks 6/13/02 OB visit 29 weeks Delivered 6/18/02 Preterm Labor Preterm Labor 2/14 Initial Visit 12 3/14 OB visit 16 4/11 OB visit 20 5/9 OB visit 24 5/15 problem 25 5/22 OB visit 26 5/29 OB visit 27 6/4 OB visit 28 6/11 OB visit 29 6/13 URI 29 6/20 OB visit 30 6/27 OB visit 31 7/5 OB visit 32 7/12 OB visit 33 7/19 OB visit 34 7/26 OB visit 35 8/2 OB visit 36 8/9 OB visit 37 2/14 Initial Visit 12 3/14 OB visit 16 4/11 OB visit 20 5/9 OB visit 24 5/15 problem 25 5/22 OB visit 26 5/29 OB visit 27 6/4 OB visit 28 6/11 OB visit 29 6/13 URI 29 6/20 OB visit 30 6/27 OB visit 31 7/5 OB visit 32 7/12 OB visit 33 7/19 OB visit 34 7/26 OB visit 35 8/2 OB visit 36 8/9 OB visit 37 Billing in additional to the global Example: Woman seen for 19 prenatal visits due to pre-eclampsia plus once post partum for hemorrhoids Six visits beyond 13 covered in global 3 visits visits CPT Global OB package ICD Mild or unspecified preeclamsia; delivered, with or without mention of antepartum condition V27.0 Single liveborn 10

11 CPT (Incision of thrombosed hemorrhoid, external ICD Mild pre-eclamp AP cond./comp (Other venous comp. in preg.; postpartum cond. Or complication Billing Incident To History CMS No new patient or problem Physician oversight Evidence of continued physician involvement OIG Audit 1 st Quarter 2007 Physicians performed 934,000 services Medicare paid $105 million Nonphysicians performed 990,000 services Medicare paid $85 million 210,000 services and $12.6 million paid to unqualified non-physicians Lacked license, certification, credentials or training OIG Recommendations Non-physicians who have necessary licensure, certification, credentials or training be under the direct supervision of the physician Use of a service code modifier to identify services not personally performed by a physician 11

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